Between Politics and Reason

Chapter 10. Alcohol and Tobacco: The Real Dangerous Drugs?

Erich Goode  State University of New York, Stony Brook

James Q. Wilson (199Oa) asks us to perform a mental experiment.
Imagine, he says, that in the 1920s, alcohol had been criminalized,
and cocaine and heroin remained legal. Would the criminalization
of alcohol have produced a criminal underworld of users and addicts?
In contrast, would the two currently illegal drugs have become
socially acceptable and widely used? If so, would the legalizers
now be claiming that it is cocaine and heroin that
are the more dangerous drugs, and that alcohol, being safer,
should be legalized? In short, are the legalizers being duped
into thinking that legal drugs are the more dangerous, not because
of their intrinsic qualities, but simply because they are more
widely used? Shouldn't we be worried about what will happen when
cocaine and heroin are legalized and, hence, much more widely
used? There's a lesson to be learned from this mental experiment,
Wilson warns.
Legalizers claim that the legal drugs, alcohol and tobacco, are
more dangerous than has been acknowledged and, in fact, more dangerous
than the illegal drugsheroin, cocaine, marijuana, LSD, methedrine
("ice"), PCP (Sernyl, or "angel dust"), and
the prescription drugs (when used for the purpose of intoxication
rather than medication). Consequently, they say, the law and its
enforcement are targeting the wrong drugs. As a result, prohibition
is both discriminatory and ineffective. Why waste tens of billions
of dollars, ruining hundreds of thousands of lives in the process,
by criminalizing the users of comparatively safe drugs
while the use and sale of more dangerous drugs are tolerated,
even encouraged?
Let's go back to a point I made early in the book and separate
two entirely different issues here: the moral/ideological and
the empirical issues. The moral or ideological issue
says, arresting illegal drug users but permitting consumers of
alcohol and tobacco to go their merry way is unfair and
discriminatory. The empirical issue says, alcohol
and tobacco are medically more harmful than cocaine, heroin, and
the other illegal drugs. The first issue, that of fairness, is
essentially unresolvable; it has its roots in philosophy and even
theology. Once again, it is a non sequitur, a "So what?"
argument. To say that it is unfair to arrest drug users and sellers
but tolerate drinkers and smokers and that, therefore, the
former substances should be legalized, does not logically follow.
There may be a variety of reasons why a given activity or substance
is banned while another is permitted; their relative dangerousness
is only one of them. For instance, penalizing one activity may
result in far more negative consequences than the other; the total
damage may tip the balance in favor of cracking down on one and
tolerating the other. Consequently, let's concentrate on the second
issue, the consequentialist or empirical question, and
ignore the first, the moral issue. More specifically, let's examine
the evidence on the relative harm of the substances in question.
What is the scorecard on harm? There is no doubt whatsoever that
the legal drugs are a great deal more dangerous than most of us
believe, while it's possible that the illegal drugs are less so.
It's hard to imagine any public health expert questioning this
point. But what about the harm of the illegal relative to the
legal drugs? The legalizers argue: Let's compare the number of
deaths from legal drugs with the number of deaths from illegal
drugs. Pile up the bodies, and which source wins? It's legal drugs,
hands down. But they also make a second empirical point as well;
they argue that if the currently illegal drugs were to
be legalized, their medical harm would decline, just as with crime
and violence. Legalized, heroin and cocaine would cause less disease
and fewer deaths than they do now.
As to the first point, let's look at the medical record, they
say. We've already seen that the two legal drugs cause or significantly
contribute to the loss of well over half a million American lives
per year430,000 for tobacco and between 100,000 and 150,000
for alcohol. The methods by which these estimates were reached
are complex and technical, and widely accepted; they need not
detain us here. The important point is that our legal drugs kill
hundreds of thousands of usersand nonusers as well, counting
victims of homicide, accidents, and passive smoke. In contrast,
the legalizers say, the total number of deaths from illegal drugs
adds up to a mere 3,500 in a recent year, according to one advocate
(Nadelmann, 1989, p.943). Are legal drugs almost 150 times more
dangerous than illegal drugs? Are alcohol and tobacco far more
dangerous than heroin and cocaine? Is this possible? Are the
legal drugs more dangerous than the illegal drugs?
The legalizers make a second and even stronger point: It is criminalization
that makes the currently illegal drugs as harmful as they
are. Legalize them, and they would be even less harmful.
Here's what legalization would do, they say: regulate the production
and sale of the now-illegal drugs, standardize the dose, make
certain that they contain no impurities, distribute clean needles
and condoms, make sure that treatment and maintenance programs
are available to addicts and abusers on a walk-in basis. All these
changes would result in a dramatic reduction in drug-related deaths
(Nadelmann, 1989, p.942).
Legal or illegal drugs: Which category is more dangerous? While
legal drugs do cause more deaths, there are at least four
problems with the legalizers' comparison between legal and illegal
drugs as sources of death. First, the comparisons that are most
often made are between apples and oranges. For the legal drugs,
deaths from all sources, as well as for the entire country,
are tallied; for the illegal drugs, deaths from only
certain sources and only in certain areas of the
country are tabulated. Second, the figures on drug-related deaths
are meaningless until they are connected to the extent and
frequency of use. Third, as I've emphasized, we don't know
whether or how these figures will change under legalization. The
legalizers are placing their money on no increases in the use
of heroin and cocaine under legalization; the rest of us aren't
so sure about this. What if use skyrockets? And fourth, the legalization
tally makes no mention of an absolutely crucial measure in the
field of public health: number of years of life lost. But
the legalizers do insist on a crucial point, one that is in their
favor: A distinction must be made between primary (or direct)
and secondary (or indirect) drug harms.

APPLES AND ORANGES

Let's start with the "apples and oranges" issue; for
the illegal drugs, we need to estimate roughly the overall total
deaths they cause. We've already seen that DAWN estimates that
430,000 drug-related emergency room episodes took place in the
coterminous United States. During the same period, 8,500 drug
abuse-related deaths were tallied by DAWN, but only 43 metropolitan
areas were included in the program (HHS, 1994b, 1994d, 1995b).
If we use the same formula DAWN used to extrapolate from the emergency
rooms they studied to the country as a whole, we come up with
a total of 16,500 acute drug-related deaths. Some of these deaths
entailed the use of alcohol in combination with illegal drugs,
and some entailed the recreational use of, or suicides by taking,
prescription drugs, that is, the illegal use of legal prescription
drugs. A few are the result of taking overdoses of over-the-counter
drugs like aspirin and Tylenol. Even so, 16,500 deaths is a very
long way from the tally racked up by the legal drugs430,000
for cigarettes and roughly 100,000 to 150,000 for alcohol.
Of course, these medical examiners' reports on drug-related and
drug-caused deaths only entail acute reactions, as well
as deaths from fairly direct medical causes. We know nothing
from the DAWN data about deaths from chronic illegal drug-related
causes. We know that most of the deaths that legal drugs cause
are from chronic, not acute, causesfor instance, lung
cancer as a result of cigarette smoking and cirrhosis of the liver
from excessive drinking. Yes, the major slice of the deaths that
the illegal drugs cause is acute in origin. This is partly because
most drug addicts, unlike drinkers and smokers, do not live long
enough to become victims of many chronic drug-related illnesses.
But at least two additional sources of death are worth mentioning;
one is nonacute in nature and the other is not, strictly speaking,
medical in origin: the first, contracting the AIDS/HIV virus,
and the second, drugrelated violence.
Half the roughly half a million to a million needle-using heroin
addicts in the country are infected with the HIV virus. It is
not unlikely that almost all of them (that is, a quarter to half
a million) will die within a decade or two. And a very high proportion,
perhaps as many as 10 percent, of the heaviest chronic cocaine
and crack-dependent abusers are similarly infected, some through
the use of needles and some as a result of engaging in unprotected
sex (McCoy and Inciardi, 1995); hence, they share the same medical
fate as the infected heroin addicts. Clearly, then, drug abuse
is a prodigiousand growingsource of AIDS-related death.
It is possible that, as a result of their use of heroin and cocaine,
25,000 to as many as 50,000 Americans a year will die of
AIDS in the early years of the twenty-first century. The legalizers
argue that these deaths are largely or entirely due to the current
ban on needle exchange programs; their numbers would drastically
decline under the plan legalizers propose. And AIDS is a secondary
consequence of drug use, but that's a separate issue. And
violence? Here, we're relying on a bit more speculation than for
AIDS-related deaths. Roughly 25,000 Americans are murdered each
year. How many are drug-related? A common estimate is that half
of all large-city criminal homicides, or perhaps a quarter of
the total, some 6,000 to 8,000, are causally related to the use
of illegal drugs. This is a lot of people, but the total is unlikely
to exceed the deaths racked up for alcohol. We discussed the issue
of whether this total would rise fall, or remain the same under
legalization in the last chapter.
Suffice it to say that, if the total sources of yearly death from
illegal drugs are tallied for the country as a whole, we'd come
up with a total many times higher than Nadelmann's 3,500 figure.
Illegal drug use is a great deal more dangerous than the legalizers
claim.

EXTENT AND FREQUENCY OF USE

Second point. To me, the key question here relates to the extent
and frequency of use: Under legalization, would the use of heroin
and cocaine rise and, with it, the damage their use causes? Many
observers say yes. I agree. As John Kaplan says, denying that
it would simply ignores one of the most basic generalizations
in the field of pharmacology (1988, p.33). Statistics on harm
must be considered with reference to total use, or prevalence.
I've already summarized the statistics on prevalence rates for
the legal and illegal drugs. Not only are there more users
of legal than illegal drugs, but their continuance rates,
likewise, are considerably higher. Suffice it to say that legal
drugs are used vastly more often than the illegal
drugs are, on an episode-for-episode basis. Roughly 60 to
70 billion "doses" of alcohol (that is, drinks containing
one ounce) and something like 500 billion "doses" of
nicotine (that is, individual cigarettes) are consumed in the
United States each year. The point is, when discussing the dangers
of these two legal drugs, we must keep in mind their total number
of users and the total number of episodes of their use.
In contrast, there are between half a million and a million heroin
addicts or more-or-less daily abusers, and between two and three
million Americans taking cocaine weekly or more (Goldstein, 1994,
p.241; Kleiman, 1992b, p.288), which add up to vastly smaller
use figures for the illegal drugs than for alcohol and cigarettes.
Estimating the total number of times addicts as well as the more
casual users of these two drugs take heroin and cocaine is likely
to be tricky; still, it is unlikely to be more than a tenth the
number of doses of alcohol and one one-hundredth that of cigarettes.
On an episode-for-episode basis, which is more dangerous: using
legal or illegal drugs? We may not come up with a clearly more
dangerous category. Different drugs kill in different ways, and
our evidence is quite messy and inexact. In the absence of more
precise measures, it should be sufficient to say that, while,
descriptively, the legal drugs kill many more Americans
than the illegal drugs do, relative to the extent of their
use, we may have something of a tie. To answer the question
definitively, we'd need more data. Both categories certainly kill
a lot of people; both categories include very dangerous drugs.
Consider the fact that heroin appears almost as often in DAWN's
lethal "overdose" statistics as cocaineand the fact
that, in the United States, cocaine is used something like 10
times as often as heroin. It seems almost certain that there is
something intrinsic about heroin itself, not the mere fact
that it is illegal, that is related to its capacity to kill.

YEARS OF LIFE LOST

Another point concerning the legalizers' flawed argument: ignoring
years of life lost. Legal and illegal drugs do not kill their
victims at the same age in the life span. The legal drugs kill
older victims, and, hence, there are fewer years of life
lost per victim; the average victim of the illegal drugs tends
to be younger, and, hence, for each death, far more years of life
are lost. Tobacco and alcohol are most likely to kill persons
in their fifties, sixties, and seventiestobacco kills those
a bit older, alcohol those a bit younger; but taken as a whole
and on average, they kill the middle-aged to the elderly. In contrast,
heroin and cocaine are most likely to kill victims in their twenties
and thirties. The fact that AIDS, almost entirely contracted from
drug-addicted mothers, is the number-one killer of children age
one to four in New York City is dramatic evidence that age cannot
be ignored in any evaluation of harm. Thus, on a death-by-death
basis, far more years of life are lost as a consequence of the
use of the illegal drugs than of the legal drugs. This point cannot
be ignored in any public health tabulation of the relative harm
of these two categories of drugs. Even factoring this into the
equation, we're still a long way from parity for the two drug
categories as a source of death, but it does tip the scales a
bit.

PRIMARY VERSUS SECONDARY HARM

One problem with any exercise which equates sources of death as
a result of the use of different drugs is that it is difficult
to separate the contribution that drug use per se makes to drug-related
medical problems, death, accidents, violence, and other measures
of harm and dangerousness from the legal status of these drugs.
That is, are the correlations between drug use and harm a primary
effect of the drug itself or a secondary product of
the circumstances of use, including the drug's legal status? Says
Mark Kleiman: "The failure to distinguish between the bad
effects of drug abuse and the bad effects of drug abuse control
sometimes reduces public discourse about drugs to gibberish"
(1992b, p.17). At the same time, in some cases, this distinction
is not always easy to make. "Some aspects of the drug problem
defy division into results of pharmacology and results of legislation"
(p. 17). We know that, by itself, heroin does not make the user
sick, and that moderate and controlled doses do not cause the
user to die. On the other hand, heroin addicts are taking a drug
that can kill them; it is heroin that causes addicts to
overdose if they take too much. It is not legal policy by itself
that causes the medical problem addicts experience, nor is it
the pharmacology of narcotics alone. We must free ourselves from
the clutches of either-or thinking; we must stop imagining that
drugs, by themselves, are magical substances that have harmful
effectsand that law enforcement alone is responsible
for the medical harm we see in addicts and abusers. It is a combination
of the two.
Nonetheless, if the currently illegal drugs were legalized, would
they inflict lessor moreharm on the American public? Would
as many users die of drug overdoses? Of drug-related disease?
The legalizers claim that, in comparison with the legal drugs,
not only are the currently illegal drugs relatively safe but they
also would be a great deal safer if they were to be legalized
(Nadelmann, 1989, pp.941-942). In opposition, the prohibitionists
argue that the statistics measuring the relative harm of legal
versus illegal drugs is an artifact of their legal status. Legalize
the currently illegal drugs, and they will become a great deal
more dangerous, not less. It is only because of their illegality
that heroin and cocaine are expensive, difficult to obtain, and
therefore relatively infrequently used; legalize them, and more
people will use themand more will become sick and die as a
result (Wilson, 1990a).
As I've already argued, here I agree with the criminalizers far
more than with the legalizers. The evidence is extremely strong
that more people would use the currently illegal drugs if the
drugs were legalized and made more readily accessible. More important,
the current addicts and abusers of heroin and cocaine would use
a great deal more frequentlyand more abusivelyif
they found that they could obtain these drugs with less cost and
less hassle than is true now. It is difficult to imagine that
anyone would discount the role of opportunity in use; regardless
of the restrictions that legalization might place in the path
of cocaine and heroin users, the restrictions would inevitably
be less binding than is true under criminalization. To the extent
that restrictions would apply, addicts and abusers would simply
seek out the illicit market for their needs. No amount of good
intentions will alter that fact.
Still, the legalizers do make several good points. First, state-distributed
drugs will be purer and more dosage-controlled than are the illicit
drugs currently sold on the street. Contamination is not the,
or even a, major problem for drugs sold on the street; a certain
proportion of the batches of illicit drugs are contaminated, of
course, but dealers who sell such goods are not likely to stay
in business very long. (Marijuana sprayed with Paraquat, once
a serious problem, hardly ever shows up any more.) Potency and
purity vary greatly from one batch to another and can pose a serious
problem for any user, but users tend to be foolhardy about the
number of doses they take at one time as well as taking several
different drugs at the same time. Variations in potency and purity
simply adds another problem on top of several others that will
still prevail, whether legalization is instituted or not. Keep
in mind the fact that the rate of death among heroin addicts in
the United Kingdom and the United States (mostly drug overdoses
in both places) is the same, about 2 percent a year (Goldstein,
1994, p.241). Although Great Britain is a long way from legalizationsome
of its jurisdictions, such as Liverpool, are a great deal closer
to it than othersit is also a system that is far more liberal
and flexible, and less punitive, than is true of the United States.
The fact that Great Britain has a somewhat different system but
practically identical rates of drug-related death among addicts
does not speak strongly for the legalizers' argument on harm.
Their point on expanding drug treatment programs (along with a
reduction in law enforcement directed at drug violators) is well
taken. The problem is, hardly any drug expert questions it. It
has become almost a truism that our priorities are misplaced;
instead of a budget that allocates 25 percent to treatment (and
education) and 75 percent to law enforcement, including interdiction
and incarceration, we should have one where this ratio is reversed.
Methadone maintenance programs should be expanded; so should therapeutic
communities. Needle exchange and condom distribution programs
promise to keep the rate of HIV and AIDS among addicts and drug
abusers from rising (Lee, 1994). Clinics in mobile vans can search
out addicts who are unwilling to come into an established program
and can distribute methadone, needles, condoms, medical care,
and information. There are many ways that the harmful consequences
of drug abuse can be kept in check short of outright legalization,
and many experts support a number of them. If nothing aside
from the factors that legalizers discuss were to change, of
course, legalization would produce less disease and fewer deaths
among addicts and abusers. The problem is, drug use is a dynamic
and volatile proposition; many observers believe that many of
the changes that legalization would bring about would result in
more medical harm, not less.

THE SCORECARD

After all the possible sources of death are consideredand we
have considered only a fewwhat does our scorecard look like?
Which is the more dangerous category of drugs: legal or illegal?
Are alcohol and tobacco more capable of causing harmor heroin
and cocaine? Focusing narrowly on acute medical effects,
there is absolutely no doubt that heroin and cocaineespecially
heroinare far more likely to cause a medical emergency and
lead to death by overdose on an episode-by-episode basis. Their
contribution to DAWN's lethal medical examiners' reports is truly
prodigious. (Alcohol causes many overdoses, most not counted by
DAWN, but it is a far, far more widely used drug.) In contrast,
focusing narrowly on direct, chronic medical effects, heroin
and the narcotics do not cause the medical pathologies that alcohol
and tobacco cigarettes do. (Incredibly, overdosing aside, narcotics
cause no life-threatening medical pathologies of any kind.) It
would be difficult for any drug to match alcohol's ravaging impact
on the liver or tobacco's carcinogenic impact on the lungs. (The
exact nature of the long-term impact of cocaineand amphetamineon
the brain remains to be seen; we already know that in large doses
over a long period of time, alcohol does damage the brain.) In
addition, the illegal drugs are indirectly implicated in
death in at least two major ways: the transmission of the HIV
virus, through contaminated needles and unprotected sex, and murder
resulting from dealing-related conflicts.
All in all, the sources of drug-related death from both legal
and illegal substances are considerable. It is difficult to select
one category over the other as incontestably safer or more dangerous.
Certainly criminalization contributes to some sources of illegal
drug-related death (violence and AIDS), but it may inhibit others
(acute and chronic medical pathologies). In the process of weighing
the relative dangers of these two drug categories, it is difficult
to come away with anything other than a mixed scorecard. Legalization
is extremely unlikely to result in all the medical benefits legalizers
argue for it. Addicts and drug abusers lead extremely unsafe lives;
a surprisingly high proportion of them drink heavilya substantial
minority of methadone maintenance patients drink at alcoholic
levelstake a variety of drugs simultaneously, use wildly different
quantities and potencies of heroin and cocaine from one day to
the next, use unsterile needles, are oblivious to nutrition, engage
in dangerous illegal activities (such as robbery), are often arrested,
and so on. While some of these factors will probably change under
legalization, the total picture is not likely to change very much,
for the one burning factor the legalizers are unable to dismiss
is a rise in drug use following legalization. This renders their
argument shaky if not specious.

CONTROLS ON ALCOHOL AND TOBACCO

As I said at the beginning of this chapter, the question of whether
it is fair or just to criminalize the possession and sale of heroin
and cocaine while keeping alcohol and tobacco legal is essentially
unanswerable; it is a moral and ideological, not a sociological,
issue. However, there is no contradiction between advocating legal
reform for the currently illegal drugseven legalizationand
tighter restrictions on the legal drugs. In fact, following
the "harm reduction" line of reasoning, it is likely
that more lives will be saved by making tobacco and alcohol less
accessible than by instituting any conceivable drug legalization
or decriminalization program. In fact, Ethan Nadelmann, a major
legalization spokesperson, has argued for control strategies aimed
at tobacco and cigarettes (1989, p.945), and Mark Kleiman, a drug
reformer who advocates limited legalization of marijuana, supports
a variety of controls on the legal drugs (1992b, 203ff., 317ff.).
The logic? Again, consider the numbers: Alcohol and tobacco kill
many more people than the illegal drugs do because they are much
more widely used; in the case of tobacco, roughly 50 million addicts
use it dozens of times each day. The legal drugs are harmful because
too many people use them far too frequently. Said another way,
the legal drugs are far too readily available; too many people
are finding it far too easy to get their hands on them. There
is practically no "hassle factor" involved in obtaining
and using them. (It is only after many episodes of usein the
case of tobacco, after literally decades of usethat the debt
for use must be paid.) Hence, the question becomes, how do we
lower the use of alcohol and tobacco? If we are serious about
rewriting legal policy to reduce harm, this is an extremely important
question.
Please note that the following discussion of harm reduction strategies
aimed at the legal drugs is not a display of my ideological or
moral biases. I am not endorsing them as strategies so much as
proposing that it they are adopted, fewer people will get
sick and die as a result of use-related ailments. This is an empirically
defensible exercise. Also note that, for tobacco at least, almost
all smokers began the habit by age 19. Hence, any strategy
that delays the onset of smoking will prolong life. This means
that the most meaningful and most viable harm reduction strategies
should be aimed at teenagers. The earlier in their lives that
potential smokers are targeted, the greater the possible impact
such a strategy is likely to have.
Can we control tobacco and alcohol abuse through the vehicle of
taxation? In fact, why not kill two birds with one stone? We could
increase taxes to reduce use and, at the same time, offset the
costs that smokers and drinkers impose on the rest of us by charging
them more for using those substances. We already know that the
cost of a psychoactive substance is correlated with its usethe
higher the cost, the lower the use. What increases the cost of
legal drugs? Why, an increase in taxation, of course; increase
the taxes on tobacco and alcohol products, and use will decline
(Goldstein, 1994, p.278; Goldstein and Kalant, 1990). The data
supporting our ability to kill (or at least wound) the bird of
high-volume use is fairly clear-cut and unambiguous. Of course,
with higher taxation comes its inevitable by-product: a certain
volume of clandestine, illegal, or underground sales of the product
that is taxed. But once again, choosing a total packagelower
use and a larger black market versus higher use and a smaller
black marketis a political and ideological not an empirical
question.
The other bird isn't so easy to kill or wound, in part because
the figures are more difficult to come by. Weighing the economic
cost that smoking and drinking impose on the society versus the
tax revenue that these products generate is an exceedingly complicated
exercise. Tracing out all the economic costs, direct and indirect,
of indulgence in these two legal drugs is not an easy matter;
as soon as we alter one factor, the entire picture changes. Moreover,
what do we include in the picture? In the case of alcohol, do
we include the increased cost of an already-substantial criminal
justice system? How do we measure the decline in productivity
that takes place when the drinker can't show up for work? Or a
decline in efficiency on the job the morning after an alcoholic
binge? Another consideration: Often, observers fail to distinguish
between costs that public facilities or nonsmokers incur ("external"
costs) and those costs that are paid for directly by the smoker
("internal" costs). And do we calculate the costs incurred
by a smoker's or a drinker's family as "external" or
"internal" costs? Likewise, consider the following:
Smokers get sick more often than nonsmokers and, hence, cost the
rest of us far higher medical bills. However, they also tend to
die at a significantly younger age; thus, they are less likely
to need medical care and collect Social Security and retirement
benefits when they become agedbecause they more rarely live
to be aged. Hence, ironically (at least in this one respect),
the smoking habit actually saves the society a great deal
of money! And, while heavy drinking is also related to an earlier
demise, this is offset by the fact that alcoholics are more likely
to retire significantly earlier than nondrinkers and moderate
drinkers and, hence, are likely to draw public benefits for a
longer period of time. Again, it should be clear that calculating
the strictly economic costs of the use of the legal drugs is an
exceedingly tricky proposition.
Alcoholic beverages are taxed about 25 cents per ounce of absolute
alcohol; this has actually declined, relative to inflation, over
the past half century. For cigarettes, the current total for local,
state, and federal taxesaveraged out nationwideis about
53 cents per pack. To put a very long and complex equation into
extremely simple terms, economic experts who have studied the
question say that alcohol taxes do not pay for the costs
they impose, while taxes on cigarettes do pay their own
way. Taxes on alcohol would have to be approximately doubled
to reach a break-even point (let's say to 50 cents per ounce
of absolute alcohol); in contrast, all things considered, each
pack of cigarettes sold only costs the society 33 cents in economic
cost, for a net saving of 20 cents (Gravelle and Zimmerman,1994;
Kotata, 1989; Manning et al., 1989; Viscusi, 1995; Warner et al.,
1995). One major difference between smokers and heavy drinkers
is the fact that drinkers are more likely to harm other parties
in addition to themselves (accident and crime victims, for instance),
while smokers are more likely to harm only themselves.
Whether we are killing one bird or two, taxation can be used as
a policy both to discourage use and to pay for the costs legal
drug users impose on the rest of us. To reduce the harm inflicted
on society and reduce use, one expert has tentatively proposed
a tax of $ 1 per alcoholic drink and $5 per pack of cigarettes
(Kleiman, 1992b, pp.248, 352). Of course, the tax rate would have
to be standardizedor at least the differences minimizedfor
all states to keep the level of smuggling to a minimum. For tobacco
at least, increasing taxation "offers the single greatest
opportunity for reducing the toll drug taking takes on American
life. There is no comparable opportunity for improving health
through policy regarding any of the currently illicit drugs"
(1992b, p.354). Another consideration: The likelihood that a proposal
entailing hugely increased taxes on cigarettes and alcohol will
be enacted within the next two decades is very nearly zero, however
much sense it makes from a public health standpoint; too many
powerful vested interests would oppose the measure and, chances
are, would also convince the public that it is in their interest
to oppose it as well. Still, restrictions on both alcohol and
cigarette consumption are taking hold nationwide on a piecemeal
basis; perhaps, eventually, the wisdom of control through taxation,
likewise, will begin to occur to harm reduction reformers. Keep
in mind that younger users and potential users, who have the least
amount of money, will be most likely to be affected by tax increases.
And keep in mind, too, that the further down the income ladder
we look, taxes on alcohol and cigarettes will take up a greater
proportion of the user's total income.
Harm reduction control strategies need not remain the exclusive
domain of federal, state, and local government; private citizens,
too, could explore ways to reduce the harm that the legal drugs
cause. Aside from increasing taxes, some possible strategies might
include:

Ban all cigarette vending machines. This not only would
reduce availability and possibly use overall but also would almost
certainly reduce use among underage smokers. Although only one
pack of cigarettes in 20 purchased by a teenager is obtained from
a vending machine, roughly 10 times as many 14-year-olds as 18-year-olds
obtain cigarettes from a vending machine. Harm reduction strategy
dictates that vending machines dispensing cigarettes be banned
altogetheror, at the very least, that they be banned in areas
that are accessible to minors.

Enforce the law against cigarette sales to minors. Some
90 percent of teenagers say they purchase their own cigarettes
(Kleiman, 1992b, p.343). Unlike establishments that sell liquor,
vendors selling cigarettes do not have a license to lose; hence,
violations are common. Knowing that selling to minors is illegal,
nearly three-quarters of vendors questioned said that they would
be willing to sell cigarettes to an l l-year-old girl (DiFranza
et al., 1987). A 1993 study commissioned by the New York City
Department of Consumer Affairs found that 48 of 60 stores sold
loose cigarettes (for 15 to 20 cents apiece) to 12-to-14-year-old
undercover agents; all the rest sold packs of cigarettes
to these same teenagers (Messenger, 1995). Perhaps licensing for
the sale of cigarettes could be explored: If vendors violate the
law by selling to a minor, they lose the right to sell cigarettes.
One study of 6,000 teenagers found that nearly half (45 percent)
were never asked for proof of age (Feder, 1996).

Increase negative advertising. The alcohol and tobacco
industry could be taxed to support a vigorous and effective campaign
designed to reduce heavy drinking and smoking. In addition, cigarette
ads blatantly aimed at children (such as the current "Joe
Camel" campaign) could be banned altogether. The misleading
and false disinformation distributed by the tobacco industrythe
alcoholic beverage industry has not launched comparable campaignscould
be offset by counteradvertising and valid information that have
a concrete impact on use. The distribution of free samples of
cigarettes could be outlawed. The effectiveness of banning all
cigarette and alcohol advertising could be explored. Would
a ban it be effective? If evidence says yes, outlaw it.

Ban the export of American cigarette products abroad. As
the number of cigarettes sold domestically declines, tobacco companies
are targeting sales to other countries. All too often this means
sales to developing Third World countries, which can least bear
the burden of crushing medical expenses and the premature death
of substantial segments of their populations. Should the American
tobacco industry have the legal right to export death abroad?
Jesse Helms, a senator from the tobacco-growing state of North
Carolina, has put strong pressure on some countries that import
U.S. tobacco to lift any and all tobacco restrictions. (Recall
that Helms urged that federal support for AIDS be reduced because
its victims brought the disease on themselves.) Such complicity
with death might be exposed, publicized, and counteracted (Goldstein,
1994, p.279; Kleiman, 1992b, p.348).

Enact legislation outlawing the use of tobacco by minors.
The fact is, purchasing a pack of cigarettes takes a few seconds,
while smoking a cigarette takes a number of minutesand, hence,
the latter is much more vulnerable to detection. Such laws should
not fall in the realm of the criminal lawentailing,
as they could, arrest, jail, prison, and an arrest recordbut
should be regarded as minor offenses, somewhere in between a speeding
ticket and a citation for driving while intoxicated. Fines, community
service, or meaningful reeducation programs would be appropriate
penalties (Kleiman, 1992b, pp.344-345).

Enact legislation further restricting public smoking. This
has begun to take place in some localesfor instance, in restaurants
in San Francisco, in restaurants above a certain size in New York
City, on most airline flights, and in many work sites nationwide.
Citizens could urge legislation further restricting where smokers
are allowed to blow smoke in the faces of nonsmokers. The nonsmoking
majority should make it clear to legislators that they endorse
their right to breathe uncontaminated air.

Enforce the drunk driving laws. At present, penalties for
drunk driving are ludicrously light and only fitfully applied.
In Scandinavia, a loss of one's license is the penalty for first
offenses, and jail sentences are imposed for second offenses;
the impact of such penalties is not clear, with some observers
arguing that the policy is effective and others claiming that
it has no effect. An experiment in Oklahoma (Grasmick, Bursik,
and Arneklev, 1993) showed that, when legal sanctions and the
threat of public embarrassment and shame for drunk driving are
combined, drunk driving declines. A variety of possible sanctions
should be explored; what counts is what works. For the most part,
however, alcohol-related auto fatalities have declined in the
United States over the past two decades, from half to a third.
Even among teenagers, the decline has been significant and striking.
We must be doing something right.

Restrict the sale of alcoholic beverages. Should beer and
wine be sold in supermarkets? In fact, perhaps the sale of all
alcoholic beverages could restricted to a small number of state-run
Alcoholic Beverage Control or "package" stores. Abolish
all "happy hours" and all other special occasions in
bars during which large discounts are offered to customers. Abolish
all sale and use of alcoholic beverages at sporting events, on
college and university campuses, on public transportation, and
at all government functions (Goldstein, 1994, p.280). While none
of these, by themselves, is likely to have a measurable impact
on drinking, they send a message and set a climate that may signal
a move to greater moderation in drinking.

Four additional points. First, the goal of such proposals is not
to catch offenders but to reduce drinking and smoking and therefore
harm; enforcement should be flexible and pragmatic, not vindictive.
Second, policy should always maximize citizen-based initiative
and minimize government intervention; the latter becomes necessary
only when it becomes clear either that private citizens do not
have certain powers or that they are unwilling to exercise them.
Third, to repeat a point worth repeating, my speculation that
these proposals will reduce harm to the society are empirical
in nature, not moral or ideological. They may sound Puritanical
and anti-hedonistic. Personally, I am very much in favor of pleasure;
I indulge in it myself. But pleasure should not be purchased at
the cost of far greater pain. Worldwide, in the twentieth century,
tens of millions of human beings have died as a result of indulgence
in the legal drugs. Does not such a tragic loss of life
deservedemandeffective intervention? How many will die
in the twenty-first century? If we do nothing, the figure could
be far greater than the number of bodies that have piled up already.
And fourth, again, to repeat an important point, very few of these
proposals have any hope of implementation in the near future,
at least in the form in which I've stated them. Right now, they
are in the realm of utopianism. But consider, as Trebach does
(1993, pp.81-82), the fact that before 1990, hardly anyone would
have given the peaceful collapse of the Soviet Union much of a
chance. He feels that this indicates that the very long shot of
some form of legalization might be possible in the United States
by the year 2000. I disagree, but my guess is, some of the preceding
controls over alcohol and tobacco are a great deal more likely.
In 1995, the American Medical Association recommended some of
these reforms (Maier and Yu, 1995). And beginning in 1996, several
former employees of the tobacco industry, a scientist and an executive,
presented documentation that high-level managers were aware of
tobacco's addicting properties and lied about this fact under
oath. Perhaps these revelations will yield valuable resources
for future lawsuits against the industry and will cripple its
capacity to sell a dangerous drug to the public. Some of the proposals
outlined above may be adopted here and there in the near future,
and perhaps many of them will be implemented during the twenty-first
century. If not, it is our loss.